March 12, 2019, 03:59 pm Michael Devitt – At 93.4 percent, Arizona is below the median when it comes to full measles, mumps and rubella (MMR) vaccine coverage among kindergarteners, according to an October 2018 Morbidity and Mortality Weekly Report (MMWR). With 93 percent to 95 percent being the threshold typically considered necessary for herd immunity, that doesn't leave much wiggle room. It's also worth noting that during the 2017-2018 school year, Arizona ranked No. 4 in number of nonmedical vaccination exemptions, trailing only Texas, Florida and Michigan.
Yet despite these numbers, state Rep. Nancy Barto, chair of the House Health and Human Services Committee, recently sponsored a series of bills that would expand the vaccine exemptions available and make it easier for parents to obtain them for their children. Barto's proposals join a hodgepodge of vaccine-related bills now in play in statehouses across the country -- some that seek to make it easier for individuals to get vaccine exemptions, along with others that aim to limit exemptions.
Meanwhile, outgoing FDA Commissioner Scott Gottlieb, M.D., recently warned states that if they don't clamp down on vaccine exemptions, the federal government may come in and do it for them.
HB 2470, the first of three bills Barto introduced last month, would add a religious exemption from vaccinations to existing law for any K-12 student and allow parents to submit their own signed document rather than mandating completion of a state health department form. In addition, the bill would add a personal belief exemption from vaccine requirements for children in daycare facilities.
HB 2471 would require health care professionals to provide information about vaccines and their benefits and risks, including the vaccine manufacturer's product insert and instructions for how to report a vaccine-related adverse event.
Finally, HB 2472 would require physicians to offer antibody titer blood testing before administering any vaccine to determine whether a child is already immune to the disease(s) the vaccine is designed to prevent.
Sarah Coles, M.D., is assistant professor in the Department of Family, Community and Preventive Medicine at the University of Arizona College of Medicine - Phoenix. She's also a member of the Arizona AFP Legislative Task Force and the Arizona Medical Association's Legislative and Governmental Affairs Committee.
"As a family medicine educator, I was privileged to help organize the family physician response by recruiting faculty, residents and medical students to engage the legislature through testimony, letter writing and social media," Coles told AAFP News. "In this role, I assisted in drafting and preparing testimony, developing strategy, and supporting future leaders in family medicine to engage in critical public health issues. It was thrilling for me to watch as my residents and students utilized their training to be bold champions of medical science to promote public health and safety for our community."
Steven Brown, M.D., program director of the University of Arizona College of Medicine - Phoenix Family Medicine Residency, was one of several people who testified against HB 2470, speaking before Barto's committee as an individual family physician.
Brown told AAFP News that when he became aware of the legislation, "My first reaction was that this is the wrong direction to be heading for public health. Vaccines are one of the most important public health accomplishments ever and have provided huge benefit for generations. I was disappointed to see an anti-science contingent in our state legislature pushing an anti-health agenda."
Andrew Carroll, M.D., an Arizona AFP delegate to the AAFP Congress of Delegates who practices in Chandler, also took issue with the wording in all three bills.
"They wanted to add language that allowed for a religious exemption," Carroll said of HB 2470. "Well, other than for the fear of the personal exemption at some point being taken away, there was no reason to add it. And as was pointed out (in testimony), there's no religion that bans or forbids vaccines. The religious exemption, it doesn't make any sense."
"The other two bills would be just a huge administrative burden," Carroll continued. Regarding HB 2471, physicians already are required to give patients vaccine information provided by the CDC, he explained. "What they wanted us to do is provide the entire package insert. That's data overload."
As for HB 2472, Carroll called out the unreliability of blood antibody titer test results. "Sometimes, the mother provides passive immunity to the infant when she's breastfeeding," he said. Administering the titer test at that time could generate a false-positive result, leading a parent to believe that their child may not require a vaccine.
"There is no place for a titer in an otherwise healthy infant, toddler or child," Carroll said.
At present, all three bills have passed out of committee and await further consideration. But Arizona Gov. Doug Ducey has already publicly stated that he will not sign any bill that could reduce vaccine coverage in the state.
"For him to come out in public and say this is a pro-vaccine state during the legislative session when a bill isn't even finished going through the legislature, that's very unusual," said Carroll. "It speaks to (Ducey's) dedication in ensuring that kids in Arizona will continue to get vaccinated."
Brown, meanwhile, warned of the potential consequences of the bills' passage for FPs and their patients.
"If these laws passed, it would lead to more administrative hurdles in the offices of family physicians," he said. "It would lead to some family physicians deciding not to give vaccines in their practices. It would lead to fewer people being vaccinated statewide and risking outbreaks of vaccine-preventable diseases that would hurt public health and the Arizona economy."
Arizona isn't the only state to consider legislation that would affect vaccine exemptions.
A bill that would make it easier to obtain a vaccine exemption has been introduced in Texas, while bills to eliminate existing religious and/or philosophical exemptions have been proposed in Maine and Vermont.
In Oregon, HB 3063 would eliminate all nonmedical vaccine exemptions for children attending public schools. And in Washington, a pair of bills making their way through the legislature would, among other things, specifically ban personal or philosophical exemptions from the MMR vaccine, as well as personal or philosophical exemptions from all school-required vaccines.
Legislatures in other states, including Iowa and Mississippi, have already rejected bills to expand vaccine exemptions this year.
In Washington, D.C., meanwhile, top administration officials have expressed concerns about existing vaccine exemption laws and suggested that federal action may be necessary to prevent disease outbreaks.
In recent interviews with Axios and CNN, the FDA's Gottlieb called the current measles outbreak in Washington "an avoidable tragedy" and blamed "lax laws" on vaccine exemptions in many states.
"Some states are engaging in such wide exemptions that they're creating the opportunity for outbreaks on a scale that is going to have national implications," Gottlieb said. If states continue to expand vaccine exemptions, he added, "I think they're going to force the hand of the federal health agencies."
Although Gottlieb didn't specify what action the FDA or other agencies might take, he alluded to possibly regulating "what is and isn't permissible when it comes to allowing people to have exemptions."
The FDA chief later took to Twitter to expand on his pro-vaccination message.
"I want to set the record straight on some common misperceptions about vaccines that are contributing to declining vaccination rates and putting vulnerable populations at risk of serious disease," he wrote in one Feb. 24 tweet. "The fact is, #Vaccineswork and they are safe."
Surgeon General Jerome Adams, M.D., M.P.H., also has touted the effectiveness of vaccines. On Feb. 1,Adams posted a three-minute video statement on Twitter about measles outbreaks and the MMR vaccine.
"I want everyone to know that the best protection against measles is getting vaccinated," said Adams, adding that he chose to get each of his children vaccinated and encourages other parents to do the same.
Keep an eye on what's happening on the public health front in your state legislature, warn Arizona family physicians Steven Brown, M.D., Andrew Carroll, M.D., and Sarah Coles, M.D. Fresh from their efforts to combat a trio of bills that would ease the path to obtaining vaccine exemptions in their state, the three encourage their FP colleagues to take the fight to their own state lawmakers when needed.
"In some states, there are opportunities to advance bills that help public health," Brown said. "In other states, like Arizona right now, you just have to play defense to prevent the advancing of bills that will harm public health. There is a disturbing trend toward the embracing of anti-science in our public policy."
"Vaccination hesitancy and movements to reduce vaccination rates are a very real and significant threat," added Coles. "The World Health Organization has listed reduction in immunization rates as one of the top 10 threats to public health in the world. However, this is not a remote threat, but one that is occurring now in our own communities. Family physicians must be vigilant and promote policy that improves vaccination rates."
"I think it's important that family physicians are heavily involved in advocating for vaccines," Carroll said. "It's not just the pediatricians who are interested in the health of children. We are protecting entire families. We're taking care of the whole family. When I tell Dad that he should get a tetanus shot to prevent the spread of pertussis, it's not just for him, but also for his 72-year-old father and for his children."
Coles urged family physicians to act to protect patients from legislative proposals that would harm public health. "Simple actions such as writing a letter, posting to social media or calling legislators takes very little time but can have a huge impact," she said.
Brown, meanwhile, encouraged family physicians to get to know their state legislators. He told AAFP News that he knows one of his representatives quite well and that she knows she can count on him to support policy interventions that would improve public health and the health of their community.
Brown also recommended that family physicians contact their AAFP state chapters about important bills coming through their respective legislatures. Most state chapters have active advocacy teams and work with lobbyists to help keep abreast of what's happening legislatively that would affect the specialty, he said.
"It is easy to get overwhelmed by what is happening at the legislature," Brown acknowledged. "The state chapters and a lobbyist can keep family physicians focused on what is most important for our patients and communities."